THEMATIC REVIEW

Theotivational motivationalhallo helloMANNERS MATTER • PART 3

THE

With its empathic style, motivational interviewing seems the ideal way to engage new clients in treatment, a psychological handshake which avoids gripping too tightly yet subtly steers the patient in the intended direction. And often it is, as long as we avoid deploying a mechanical arm.

by Mike Ashton of THE MANNERS MATTER SERIES is about how services has been on reinforcing ‘motivation’, an amalgam of Thanks to Bill Miller, Jim can encourage clients to stay and do well by the acknowledging a problem, wanting help, and resolv- McCambridge, Dwayne Simpson, 5 Don Dansereau, Gerard Connors, manner in which they offer treatment. Parts one and ing that treatment is the help you need. and John Witton for their comments. two dealt with practical issues like reminders, trans- Once thought of as something the patient either Thanks also to Bill Miller, Janice port and childcare. Even at this level, more is in- did or did not have, motivation is now seen as a fluid Brown, Terri Moyers, Paul Amrhein, John Baer and Damaris Rohsenow volved: respect; treating people as individuals; state of mind susceptible to influence. Of the ways for help with obtaining and conveying concern and caring. to exert this influence, motivational interviewing is interpreting their work. Though they 6 have enriched it, none bear any From here on, relationship issues take centre by far the best known. It qualifies for this review responsibility for the final text. stage. Relegated by medicine to the ‘bedside man- because it is more about how to relate to the client ners’ which lubricate the interaction while technical than what to say or do.8 treatments do the curing, in psychological therapies, We can see where it fits in through a model bedside manners are the treatment, or a large part of which encapsulates research on the processes under- it.1 2 3 We start with how to ‘say hello’, and specifi- lying effective treatment and the points where these cally with motivational interviewing’s role in prepar- could be promoted by interventions A model of ing clients for treatment (‘induction’), the role for treatment, p. 24.9 Motivational interviewing is among which Bill Miller created it.4 the “Readiness interventions” in the top left hand corner. Its importance is that the more motivated the MOTIVATION CAN BE MOVED patient is, the deeper their initial participation. This Induction strategies aim to prime the client for is linked to staying longer which in turn is linked to treatment by telling them what to expect, addressing better outcomes.10 11 12 Via this chain, if motivational concerns, enlisting support, and strengthening interviewing does boost motivation, it should in- psychological resources. But most of all, the focus crease the effectiveness of subsequent treatment.

Positive verdict from aggregated research

Before analysing individual studies (numbered from enth and tenth in their league tables of evidence of 1 to 19i), we’ll take what we can from analyses which effectiveness, outranking many treatments which have amalgamated these studies. Conclusively, these take longer and cost more. Other analyses have tell us there is something here worth investigating. confirmed this conclusion, and added that the ben- From diabetes to problem drinking, high blood efits were significantly greater when motivational pressure and poor diet, motivational approaches help approaches were an induction to substance misuse patients adhere to treatment and change their life- treatment rather than a standalone therapy.15 16 18 19 styles more effectively than usual clinical advice.13 A later analysis added two further observations.20 For drinking in particular, it has a better research First, that the gains from motivational induction are record than practically any other treatment.14 15 16 greater because they persist over at least the next 12 But these omnibus verdicts conflate very differ- months while those from standalone therapies de- ent scenarios. For current purposes, the ideal analy- cay. Second, and contrary to expectations, therapists sis would focus on people seeking treatment rather had less impact when they followed a manual. This than identified through screening, and then on finding’s far-reaching implications are explored later induction studies rather than studies of motivational Is it dangerous to follow the manual?, p. 28. interviewing as a treatment in its own right. It would The final analysis focused on turning up for and then assess whether treatment participation was sticking with treatment or aftercare.21 Most of the productively deepened by motivational preparation. studies it pooled were of substance misuse. On the None precisely fit the bill, but some come close. basis that 12 found significant advantages for moti- vational interviewing, five that it was as effective as STRONGEST RECORD IN INDUCTION STUDIES other approaches, and just four found no benefits, Two analyses take us part way there.14 17 Among the authors declared themselves “cautiously optimis- drinkers known or presumed to be seeking treat- tic”. Though the weight of the evidence was positive, ment, these ranked motivational approaches elev- in three of the substance misuse studies (3, 6 & 10)

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and in another not in the review,25 motiva- duction approach would do as well or better, approaches,19 or that it improved outcomes tional induction had no impact on starting including feedback in another style. Then by enhancing engagement with treatment. or sticking with treatment. The reviewers there were the negative studies and, for To get more of a grip on these loose argued that retention was already so good some, no convincing explanations why ends, the individual studies in these analyses that there was little room for improvement, motivational interviewing failed in these but and several later studies were analysed in but in two studies (6 & 10) this does not not in others. Finally, we have greater confi- depth Get the full story, p. 26. What follows seem to have been the case. dence that one thing causes another when focuses on the patterns which emerged. we can see the levers connecting the two, yet Rather than definitive conclusions, the LOOSE ENDS the reviewers found little evidence that interpretations offered here are an attempt Of the loose ends left by these analyses, motivational interviewing actually did to make sense of these patterns and to rec- loosest of all was whether some other in- stimulate motivation more than alternative oncile seemingly inconsistent results

Albuquerque air: the first studies of drinkers

The earliest trials of motivational interview- (when the cap fitted) dubbing patients ened the profile of the therapist’s interper- ing were conducted by Bill Miller’s team at ‘alcoholics’. As expected, the empathic style sonal style, seeming to confirm that the style Albuquerque in New Mexico. While thera- did result in greater reductions in drinking, mandated by motivational interviewing was pists had the benefit of expert tuition and but the differences were small and fell short preferable to confrontation. The stage was oversight from the approach’s originator, as of statistical significance. set for trials of the approach in its intended yet there was no manual for them to follow. The reason may have been that in prac- role – as a prelude to further treatment. tice the therapists did not implement radi- PROMISING STANDALONE INTERVENTION cally distinct approaches. Only when the STARTLING IMPACT IN INDUCTION STUDIES First it was tried as a standalone brief inter- focus was shifted to how they and their In 1993 results were published from the first vention combined with feedback from the clients actually behaved did clear and signifi- trials of motivational interviewing as a prel- Drinker’s Check-up, a battery of tests of cant relationships emerge. The more the ude to respectively in- and out-patient treat- alcohol use and related physical and social therapist had confronted (arguing, showing ment. In contrast to the check-up studies, problems. Though concerned enough to disbelief, being negative about the client), patients had arrived for treatment via nor- respond to ads for the check-up, participants the more the client drank a year later. The mal referral routes and were much heavier were not the highly dependent ‘alcoholics’ same was true of ‘resistant’ client behaviours drinkers and more severely dependent. normally seen at treatment services. like interrupting, arguing, or being negative In both trials, a non-directive, one-on- about their need to or prospects for change. one motivational session preceded consider- Comparing immediate against delayed These client and therapist behaviours ably more directive 12-step based group 1 motivational feedback suggested that were closely related. For motivational inter- therapy.21 There was a real chance one this approach could motivate reduced viewing, the favoured interpretation is that would undermine the other, but the oppo- drinking and treatment entry among this when therapists departed from its non- site happened. Given that it was a brief type of client.27 The non-stigmatising offer confrontational style, clients were provoked prelude to more extended treatment, moti- of a check-up seemed to enable many to in to hitting back or withdrawing. The vational feedback caused startlingly large take a first (if often incomplete) step towards pattern of results suggests this was at least reductions in post-treatment drinking. cutting down or seeking help, without part of what was happening. An alternative violating their self-image as non-alcoholics. explanation is that resistant clients provoked The outpatient trial compared it with a the therapists into non-motivational responses 3 typical ‘You are an alcoholic and must The next study was similar, except that related to poorer outcomes with this kind of return for treatment’ induction.22 During 2 feedback was provided in one of two client.29 It certainly can happen,30 but other the succeeding months, the interview led to styles.28 One was the empathic motivational studies with similar findings have been able virtual 100% remission, perhaps partly style, the other the supposedly counter- to eliminate this possibility.29 31 32 33 because it avoided solidifying patients’ productive style it aimed to improve on: Conceivably, both processes were in identities as ‘hopeless alcoholics’. Without explicitly directive, confrontational, and play. Whatever the truth, the study height- it, a substantial minority of patients contin- ued to drink at alcoholic levels, fulfilling the identity they had been given during induc- A MODEL OF TREATMENT tion and later treatment.

Readiness Behavioural interventions Social skills and support Social support systems interventions The inpatient trial was run on similar 4 lines, except that the comparison group What simply progressed through normal proce- goes on Patient attributes EARLY ENGAGEMENT EARLY RECOVERY STABILISED Post-treatment RECOVERY 26 inside Readiness outcomes dures. From before treatment consuming ii treatment Severity Programme Behavioural Recovery about 20 UK units a day, the motivational (orange participation change support patients cut down to on average four units; box) and networks how it Programme controls were still drinking 13 units a day. A might be attributes Drug use new finding was that these benefits seemed influenced Resources Criminal to be due to motivational induction deepen- by inter- Therapeutic Psycho-social Sufficient activity ventions Staff ing engagement with the programme, an Climate relationship change retention Social (white relations Management effect revealed by staff ratings of compliance boxes).9 information with therapy. Here were some of the ex- pected levers in action: motivational prepa- ration leads to deepened engagement leads Systems Cognitive interventions Recovery skills training Personal health services interventions to less post-treatment drinking.

24 DRUG AND ALCOHOL ISSUE 13 2005 THEMATIC REVIEW RESISTANCE TO TREATMENT is the central reality ad- dressed by motivational induction.56 In his first account of motivational interviewing,57 Bill Miller noted that many Leaving home: attempts to replicate early findings with drinkers clients resist because they reject stigmatisation through a process which entails being pigeon-holed as an ‘ad- Attempts elsewhere to replicate the early retention. This could have been because the dict’ or ‘alcoholic’ no longer in control their lives.58 Oth- induction findings had mixed results, per- patients already recognised their alcohol ers may accept this yet be unconvinced that treatment haps partly for technical reasons (eg, which problems and said they were working hard will help.59 60 Coerced patients may not think they have a results were measured) and partly because to resolve them – and understandably so. problem at all and resent being forced to get ‘it’ treated. the therapy, by now often hardened into Nearly all had lost whatever jobs they’d had, Others doubt the relevance of drug-focused treatment manual form, failed to adapt to the patients. most had lost husbands or wives through to what they see as their most urgent priorities.61 62 divorce, each averaged over a decade of They encountered treatment services which de- MORE IMPACT THAN ROLE INDUCTION dependent drinking, and they had gone so manded immediate abstinence, treated their patients as One uniquely important study far as to commit to and begin an intensive the embodiment of an addiction, and rarely offered ef- 5 not only tested whether motivational six-week programme. fective help with the family, housing, employment, fi- interviewing led to less drinking than For those who left early, the problem was nancial or other issues heading their list of concerns.63 64 normal procedures, but whether it led to unlikely to have been a failure to recognise This mismatch can still be seen in British drug services.65 less than ‘role induction’ – the most popular the debit side of drinking. Given the stage US researchers and clinicians observed the results: alternative induction method – and if it did, they had reached, leading them to reflect on most dependent substance users avoided treatment or whether this was because it truly did deepen the positives of their drinking may also have quickly left.57 One interpretation of the genesis of moti- engagement with treatment.34 On all counts, seemed a disconcerting backward step. vational interviewing is that rather than realigning treat- the answers seemed ‘Yes’, though effects ment, a way was found to get the patient to realign them- were neither large nor could they be se- ROOTED IN RESISTANCE: THE ORIGINS OF MOTIVATIONAL INTERVIEWING curely attributed to motivational induction. Compared to other induction samples, selves via a roundabout route which gave them the 126 alcohol abusers (no diagnosis of less to react against.66 But the spirit of the ap- dependence was required) who joined the proach demands that treatment too must ad- study at an outpatient unit in Buffalo drank just to the patient. less heavily and more had retained employ- Swimming against the strong US disease- ment and intimate relationships. Those model tide, Dr Miller argued that the ‘addict’ randomly assigned to the motivational should be treated (in both senses of the word) interview went on to attend 12 out of 24 as someone who behaves just as ‘we’ might in therapy sessions compared to eight for the a similar situation – someone whose self-per- controls. This partly accounted for the fact ceptions and desires are to be respected as the that during treatment and the 12-month valid expressions of a “responsible adult” ca- follow-up, motivational patients drank pable of making their own decisions.57 67 From heavily on fewer days and used other drugs It doesn’t have to be this way – push, push back, get nowhere this perspective, resistance is neither the mani- less often – again, the elusive ‘levers’ in festation of a character flaw nor a symptom of action. Retention itself may have been aided DIFFERENT DRINKERS, DIFFERENT FORMAT disease, but a product of interactions with therapists who by the fact motivational induction helped Remaining studies either involved special impose their views of who/what the patient is and what patients quickly curb their drinking. types of clients or departed from a main- they need, telling the client what they ‘must’ do, imply- Important ingredients may have been an stream motivational intervention. ing they are powerless, arguing, and confronting. emphasis on motivational principles rather Dr Miller developed an approach which sidestepped than a pre-set agenda, skilled and perhaps DUAL DIAGNOSIS PATIENTS these and other deterrent interactions.The result was motivated exponents, and a caseload which One involved substance (mainly motivational interviewing. One way to think of it is as a embraced those with relatively moderate 8 alcohol) abusing psychiatric patients crystallisation of interpersonal styles which create a trust- problems who could have needed some with quite severe life problems starting a 12- ing, open and egalitarian relationship, and then use this priming to commit to treatment. Together week US day hospital programme.35 Com- as a communication medium across which influence can with earlier work, the study provides strong pared to a standard psychiatric induction, an flow without disrupting the connection.21 42 The ‘crystal- (but not incontrovertible) evidence that in initial motivational interview extended lisation’ consists of principles common to many thera- these circumstances, assessment plus moti- average retention from 22 to 31 days. De- pies like ‘expressing empathy’, and specific tools like ‘re- vational feedback can aid treatment. spite retaining people who would otherwise flective listening’. Its main engine for change is the have left, it also improved their punctuality amplification of conflicts between the client’s goals and SET AGENDA MANDATES WRONG FOCUS? and halved the number of days of substance values and their substance use.67 68 In contrast, a British study failed to use while in treatment. Directive in intention if not in words 6 confirm the promise of the early US The interview incorporated feedback Even if the client envisaged by motivational interviewing work, possibly because for these patients its from prior assessments and a decisional is at least to some degree ambivalent about their goals, version of motivational interviewing man- balance exercise, but seemingly followed no the therapist typically knows where they want to get to 23 dated an inappropriate focus. set programme or manual. and systematically seeks to get there.67 In this sense, like Subjects were 60 dependent drinkers more up-front tactics, motivational interviewing is ‘direc- randomly allocated to one of two extra HOW BRIEF CAN YOU CAN GET? tive’; the difference is that it seeks to generate momen- interventions when starting a day pro- Among the loose ends left by the early US tum by not being explicitly directive with the client.15 gramme in Bournemouth. One was a pre- work was whether some other non-confron- Ethical issues raised by this more covert approach have structured motivational intervention tational feedback approach might work as been addressed by Bill Miller,69 who accepted that it focused on eliciting from the patient the well. One possibility is simply providing could be used to pursue goals which were not those of pros and cons of drinking and amplifying new patients written materials – not as the client,57 departing from its client-centred ethos.67 He 36 37 the salience of the cons. It was compared to unlikely as it may seem. argued for the client’s goals to be respected – but from a education on the effects of drinking, using position where the therapist had their own ideas of what feedback of the client’s answers to a “quiz”. For induction purposes, the most their problem was and what would constitute “unwise” Motivational induction had no impact on 9 relevant study was conducted at a and what “healthful” paths forward. The aim was get the patient themselves to come to a matching conclusion.

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SECOND SIGHT Carl Rogers Toronto addiction treatment centre.38 On alternate A message from Albuquerque What happened months each new alcohol patient was handed the Alcohol when he let a and You booklet at the end of their intake assessment. by Bill Miller troubled mother tell 4 Motivatonal interviewing’s founder, University of New Mexico her own story Written by Bill Miller, this combined motivational convinced him that elements and individualised assessment feedback I got interested in this field on an internship in Milwaukee. The the therapist’s task comparing the drinker to national norms. It invited is to rely on the psychologist-director, Bob Hall, enticed me to work on the alco- readers to reconsider their drinking but did not advocate client for direction – holism unit, even though (and because) I had learned nothing the person-centred return for treatment, an attempt to avoid its rejection by about alcoholism. Knowing nothing, I did what came naturally to approach which people who had decided not to come back. me – Carl Rogers – and in essence asked patients to teach me inspired Despite this, patients given the booklet were slightly about alcoholism and tell me about themselves: how they got to motivational more likely to return, but the biggest effect was to sub- interviewing. where they were, what they planned to do, etc. I mostly listened stantially reduce drinking over the next six months, with accurate empathy. especially among the minority who did not come back. There was an immediate chemistry – I loved talking to them, These findings underline the twin arguments for moti- and they seemed to enjoy talking to me. Then I began reading vational induction: not only may it promote engage- about the alleged nature of alcoholics as lying, conniving, defen- ment with treatment, but it also constitutes a potentially sive, denying, slippery, and incapable of seeing reality. “Gee, effective brief intervention for those who drop out. these aren’t the same patients I’ve been talking to,” I thought. The experience of listening empathically to alcoholics stayed with Beyond drinkers: pluses and minuses me, and became the basis for motivational interviewing. For users of drugs including heroin, cocaine and canna- Crash – and I wrote the manual! bis, motivational interviewing has now been tried dur- To me our drug abuse study was a clear example of manuals fail- ing the waiting period for treatment and the initial ing to adapt to the patients study 13. I am now working on a stages. Results have been mixed, perhaps because the paper which collapses the two ‘poor outcome’ groups (strugglers patients themselves were mixed in the degree to which and discrepants) and the two ‘good outcome’ groups (changers they needed a motivational boost or were at the stage 44 and maintainers). Their speech patterns are strikingly different. where they could benefit from one. Relative to good outcome patients, those who will have poor outcomes showed two substantial deviations. They backpedalled BRIEF RESPITE VERSUS INTENSIVE MARATHON around the third decile [tenth of the session]. Commitment Two studies have trialed motivational interviewing to strength stopped climbing, and instead flattened out or fell. Then tide people over while waiting for treatment to start. around the sixth decile it started picking up again, and actually Though really pre-induction, the results are relevant. In reached the same point at decile 9 as the good outcome group. one there was no impact, in the other, long-lasting In decile 10, however, it fell abruptly back to zero. benefits. The difference may have been down to the “What were you doing to these people?” Paul Amrhein [lan- degree to which motivation was the issue. guage analyst] asked. The answer is that in deciles 1 and 2 we I BEGAN READING ABOUT ALCOHOLICS AS In Washington, the unsuccessful trial inserted LYING AND DEFENSIVE. “GEE, THESE AREN’T THE SAME PATIENTS I’VE BEEN TALKING TO.” 10 measures including a manual-guided motiva- tional interview between the time drug (mainly cocaine) were doing pure motivational interviewing. Around decile 3, we abusing patients had been referred for treatment and started assessment feedback. About 70% of patients went with it their first appointment.24 A relatively full-featured and showed the expected effect of increasing commitment to attempt to bridge this gap, it made no difference to how change, but the poor outcome group did not. They seemed to many patients started or completed treatment (a com- balk at or resist the feedback. I gave the therapists no choice in mendable 71% in both cases) or how well they did. the manual but to continue with the feedback. Then around decile The 654 who joined the study typically suffered 6, the therapists went back to pure motivational interviewing. severe and multiple problems (including poor housing), Then the manual says to develop a change plan by the end of and were overwhelmingly committed to the treatment the interview. Again, the manual (which I wrote!) left no flexibil- GET THE on offer. For 85%, this was a short stay in hospital – ity. The essential message was, develop a change plan whether FULL STORY conceivably an attractive respite from the streets, espe- or not the patient is ready. Crash. Any decent practitioner would This analysis is cially since most did not face opiate withdrawal. Those know not to persist when patients start balking. distilled from an who nevertheless failed to turn up were probably less in extended review Best for the ambivalent? available free on need of a motivational boost than of intensive support. Your collection of studies suggesting an adverse effect with mo- request from tivational interviewing for ‘more-ready’ clients is an important ob- editor@ A Spanish trial provides an instructive contrast. servation. The same direction is there in the anger match in Project drugandalcohol 11 The marathon Proyecto Hombre rehabilitation findings.org.uk. programme attracted mainly heroin users living with MATCH. Low-anger clients showed somewhat worse outcomes Note that the aim is 39 40 with motivational therapy relative to the other two treatments. I to investigate their parents or in their own family home. It started can understand motivational interviewing having no effect with motivational with roughly a year-long day programme during which clients who are already ready for change, but the seeming ad- interviewing as a the families came with the clients. Before this phase was preparation for verse effect, now observed in several studies, seems surprising. half way through, four out of five had dropped out. patients seeking The clinical sense I can make of it is that when clients are ready treatment without Seeking ways to stem the outflow, detoxified patients to go, it is not time to be reflecting on whether they want to do being legally awaiting entry were randomly allocated to normal so. Motivational interviewing was originally envisaged for work- coerced to do so, procedures or to a three-session motivational interven- ing with people who are ambivalent or unclear about change, rather than as a tion, structured according to a broad outline rather than treatment in its own a detailed manual. Three months into treatment, the and perhaps that is the group for whom it will be most helpful. right or a way of encouraging take-up motivational group showed improved retention. The of aftercare. gap grew until by six months half were left compared to

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just 1 in 5 after normal procedures. being trialed its creators, presumably enthu- session motivational interview on days one These Spanish addicts had the home siastic exponents. Perhaps also, as its ‘own- and four, conducted by therapists trained support lacking in Washington, potentially ers’, the Australian team had the licence to and supervised to follow a detailed manual. leaving their commitment to the pro- adapt it. Where they stressed skilful flexibil- There was no overall effect on transfer rates, gramme as the main influence on whether ity, the other two papers suggest a more but the interviews did help less motivated they stayed. No respite from the streets, this prescriptive implementation. The initial patients complete detoxification and transfer was an extraordinarily extensive and inten- focus on the positives of substance use may to aftercare. By doing so, they might have sive programme which would dominate need particular care unless, as with metha- been expected to lead to a higher relapse rate their lives for nearly two years. Wavering done patients, it simply acknowledges an during aftercare. The opposite occurred. commitment would have provided fertile undeniable and current reality for the client. More motivational patients started aftercare ground for motivational interviewing. cocaine-free and over the next 12 weeks “PUZZLING” FAILURE WITH DRUG USERS they continued in the same vein. MIXED RECORD AS INDUCTION METHOD A ‘developer effect’ was notably Drug use reductions seen in this study The few direct tests of motivational induc- 13 lacking when Bill Miller’s team and the extra impact on less motivated tion for heroin or cocaine users confirm that extended their work to drug users. The patients were both absent in Albuquerque it is most beneficial for those ambivalent study took place in Albuquerque at his study 13. A possible reason is the way the about treatment and go further, showing university’s outpatient centre and at an 43 Like a whisper in that it can actually be counter-productive for inpatient detoxification unit. For most of the ear, a motivational more committed patients. the 208 patients, cocaine (especially crack) interview can have a was their primary problem, and for nearly dramatic impact, but just what that is de- The first such study took place at an one in three, heroin. pends on the relation- 12 Australian methadone clinic.41 42 Half were randomly allocated to con- ship, the situation, There researchers had structured the moti- tinue as normal and half to a motivational what’s said, and how it fits into what went vational style into a one-hour ‘bolt-on’ interview conducted by therapists trained before and what is module (plus a brief review session a week and supervised to follow a manual. On yet to come. later) consisting of a seven-point agenda. practically every measure taken and no As adapted for heroin users, a brief ex- matter how the sample was divided up, the patients entered treatment, in Albuquerque amination of what they see as the good side interview made no difference to motivation via normal routes, in Houston, via ads for of heroin use is intended to establish this as for change, retention, or drug and alcohol the study. Judging from their motivational a chosen rather than an out-of-control use outcomes over the next 12 months. profiles, many in Houston would not have behaviour. Then the focus is on eliciting Among the possible explanations are that, sought treatment unless prompted by the and amplifying the client’s account of the according to paper-and-pen tests, nearly all ads; motivational interviewing had some- debit side of heroin use, featuring a balance the patients were in no need of a motiva- thing to bite on. sheet of the pros and cons completed at tional boost, but an analysis of what they home for review at the follow-up session. actually said in counselling sessions seems AND EMPLOYED PRIVATE PATIENTS Compared with educational sessions on to belie this interpretation.44 Several other A similar study which used a similar opiate use, on average motivational induc- explanations are feasible. For one, the same 15 measure of motivation also found tion extended retention from about 18 to 22 analysis provided empirical confirmation: that this determined how patients would weeks and delayed relapse to heroin use, the study’s inflexible, manualised approach react.46 The programme was a day-hospital consistent with an impact on outcomes via to motivational induction had left insuffi- regime in Rhode Island with an abstinence retention. However, improved retention cient room for therapists to adjust and and 12-step orientation. Over 7 in 10 of the may itself (as in study 5) have been due to provoked counterproductive reactions when cocaine-dependent patients who joined the the interviews helping patients rapidly its instructions clashed with the client’s state study smoked crack, but at this private curtail substance use.iii of mind Care too with the unconvinced, p. 38. facility they were not the poor minority How can we account for these findings, caseload seen in Houston study 14. when adaptations of the same model for DEPENDS ON INITIAL COMMITMENT Half were randomly allocated to a moti- drinkers and cocaine users failed to improve The next two studies found that motiva- vational interview planned for day two and on normal procedures studies 6 & 10? tional induction had no overall impact on half to meditation and relaxation. Therapists First, in contrast to these studies, many of retention, but also that this masked positive were trained and supervised and motiva- the Australian patients were ambivalent impacts among patients who saw themselves tional sessions recorded to ensure they about ending substance use. After all, pa- as still thinking about curbing drug use competently followed a manual. Though tients starting methadone treatment clearly rather than having started the process. Less the emphasis could vary,47 this prescribed an are not yet ready to see use of opiate-type expected was a negative effect among the exploration of the pros and cons of cocaine drugs as an unambiguously bad thing. latter. These findings are explored later use, how use or non-use fitted with the Another key may have been the holding More committed react badly, p. 28. patient’s goals, feedback of a prior assess- power of the intervention over the week ment of their drug use and its consequences, between the sessions. Patients appreciated AMONG INDIGENT POOR and the formulation of a change plan. the chance to explore their experiences with In Houston, 105 cocaine users At issue was whether this would improve a “highly skilled” therapist who rapidly 14 started a ten-day outpatient ‘detoxifi- on the inactive and it was thought ineffec- established rapport. To return for ‘closure’ cation’.45 Most were black and unemployed tive relaxation approach. The answer was a of this valued intervention, they had to stay and smoking crack. Patients who achieved surprising ‘No’. Patients as a whole did well, on methadone for at least the first week after abstinence could transfer to relapse preven- but on none of the measures of retention or being stabilised, a vulnerable period. More tion aftercare. The issue was whether outcomes up to 12 months did the motiva- did so than after the alternative induction, starting detoxification with a motivational tional interview further improve things. As accounting for better long-term retention. interview would improve transfer rates. in Houston, this was not because the inter- Underneath it all may have been the Patients were randomly allocated to view itself was inactive, but because it had ‘developer effect’: the intervention was normal procedures or additionally to a two- opposing impacts on different patients.

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Is it dangerous to follow the manual? acted badly. It seems that motivational interviewing of this kind is as capable of Manual-guided programmes have become ALSO IN AFTERCARE STUDY knocking back more motivated patients as it seen as essential for any treatment which The third study concerned alcohol is of helping those in need of convincing. claims to be evidence-based.48 The research 19 patients admitted for on average five The explanation might be what to the rationale is to standardise ‘inputs’ so these days of inpatient detoxification in Rhode patient could have seemed an undermining can be related to outcomes, the clinical Island.51 It has not featured so far because backward step to re-examine the pros and justification, that they enable clinicians to the aim was to motivate take-up of aftercare. cons of whether they really did want to stop “replicate” proven treatments.49 After settling in for at least a day, ran- using drugs or commit to treatment and An alternative view is that such detailed domly selected patient intakes were allo- aftercare, when they had already decided to programming cramps client participation cated to one of two types of induction. The do so and started the process. Other unsuc- and clinical judgement3 and focuses atten- first was five minutes of advice which com- cessful induction trials might also be ex- tion on techniques rather than ways of prehensively contravened motivational plained by the relatively high commitment relating which cut across therapies.2 If these are what matters, then the baby could be exiting with the bath water. Such prescrip- Compared to the Patients completing Days used by users Drinks per drinking day tiveness seems particularly risky for motiva- alternatives, motiva- detoxification Patients abstinent Days abstinent tional induction re- 100% 0% 100% tional interviewing, whose essence is to duced substance use 100% 75% 25% 75% respond to clues from across the table, and among low motivation 75% Cocaine use Drinking whose mantra is that the “responsibility and patients but increased 50% 3 mth follow-up 50% 50% 0 50% 3rd follow-up mth capability for change lie within the client”.50 it among the highly 25% 75% 25% 6 Support for this view comes from a motivated, signified by 25% the crossing lines. recent meta-analysis.20 The studies it ana- 0% 14 0% 15 100% 0% 19 12 Low High Low High Low High lysed differed in how they implemented Motivational induction Alternative procedures Motivation Motivation Commitment to AA motivational approaches. Of all the varia- tions including duration, how many motiva- Better outcomes tional-style principles and techniques were said to have been deployed, and therapist interviewing’s code. Patients were told they of the clients allied with an insufficiently training and support, only one was related to had a significant drink problem, that absti- flexible approach studies 6, 10 & 13. outcomes – whether the therapist followed a nence was very important, and to get as manual: manualised therapy had less impact. involved as possible in AA aftercare groups. CARE TOO WITH THE UNCONVINCED The second type of session was a one- One of these trials (13) uncovered another MORE COMMITTED REACT BADLY hour motivational interview. It also advised hazard of prescriptive therapy – failing to This result could have been due to differ- abstinence and AA, but not in the unam- back off in the face of continuing ambiva- ences between the studies other than biguous manner of the more abrupt inter- lence. Though the hazard is different, the whether they used a manual. But signs of vention. Instead, patients were led through study provides insights into how both sorts the same effect can be seen within studies. In exercises weighing the pros and cons of of mistakes can occur. three, motivational induction helped ‘low abstinence and AA and exploring how Despite considerable experience supple- motivation’ patients but retarded those mented by 16 hours’ training and feed- “THE PARADOX OF MANUALIZATION IS THAT more committed to action charts. THE PATIENT’S ACTIVE INVOLVEMENT IS LIKELY TO back on their videoed performances Each time, therapists were supervised BE ESSENTIAL TO GOOD OUTCOME BUT from Bill Miller, who personally certi- 3 to ensure they adhered to a detailed manual DESTRUCTIVE OF EXPERIMENTAL CONTROL” fied their competence, the study’s moti- which prescribed ‘decisional balance’ exer- drinking conflicted with longer-term goals. vational therapists failed to improve cises, leading the patient to review the pros Finally, they were asked to choose their own retention or outcomes. and cons of changing substance use or goals for attending AA groups or were in- In this study, so tightly was the interview engaging in treatment or aftercare. formed of alternative sources of support. programmed through a detailed manual, and Two of the studies have already featured Among patients whose current plans and so diligent, well trained and closely super- in this article. Both involved mainly cocaine past records of attending AA/NA indicated vised were the therapists, that they intro- users attending a short-term day detoxifica- less commitment to AA, the interviews had duced the same topics at roughly the same tion programme, and divided patients into the expected effects. They abstained more point with all their clients. It enabled what those typified more by ‘taking action’ to often, and when they drank, drank less than clients and therapists said to be matched to tackle their substance use as opposed to ‘still patients given brief advice. But this was the topics addressed in each succeeding thinking’ about it. counterbalanced by an even greater negative tenth of each session.44 52 In Houston (14), motivational induction effect on more committed patients. Analysis of the videotapes suggested that improved completion rates among ‘still Over a six-month follow-up, as long as it was not (as previously believed20 53) the thinking’ patients, counterbalanced by the patients most committed to AA had been frequency of ‘change talk’ which related to opposite effect in those who saw themselves directed to abstain and attend the groups, outcomes, but the strength of the client’s as having already started this process – they and those least committed had been through determination to change versus to stay as did worse after the interviews. These effects the motivational exercises, on average each they are. The difference between ‘I hope to’ were substantial and statistically significant. sustained near 100% abstinence and drank and ‘I will’ (or similar) was more important In Rhode Island (15), consistently the little when they did. When this matching than how many times either was said. interviews worsened cocaine use outcomes was reversed, outcomes were far worse. among ‘taking action’ patients while (to a WRONG MOVES AND PREMATURE CALLS lesser and non-significant extent) improving TWO STEPS BACK? During the first five to ten minutes of each outcomes among those ‘still thinking’. In all three studies, the puzzle is not why session clients were asked what had led Seemingly no fluke, there was a similar the least committed benefited (this is ex- them to seek treatment. Here the strength pattern with drinking. pected), but why the most committed re- of their commitment to reduce drug use

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simply reflected how far they had already gree of directiveness by the therapist. If this lining: the strength of the client’s commit- done so. From then on, commitment can be seen in motivational therapy, it ment to change at key junctures was so strength started to respond to what the should also be apparent elsewhere. closely related to later drug use, that from therapist was doing, and instead of reflecting This is territory to be covered later in the this alone one could predict with remark- where the client had come from, became a Manners Matter series. Here it’s relevant to able precision (in 85% of cases) who would potent predictor of where they would end note the key finding: patients who like to do well and who would struggle. up in a year’s time. feel in control of their lives, who react As required by motivational interview- The first clue came around the middle of against being directed, and resist therapy, do ing, the therapists had created a non-judge- each session when clients had received best when therapists are less directive (as in mental social space within which what the feedback from an assessment of their drug true-to-type motivational interviewing), client said was a valid reflection of their state use and related problems. As intended, while those willing to accept direction do of mind and determination to change, rather about 70% expressed sustained or increased better when this is what they get.29 31 32 33 than acting as a way to placate, save face, or commitment to tackle these problems. Over terminate the encounter. The problem was the following year, they largely remained ACCEPTANCE ELICITS HONESTY that therapists were so constrained that they abstinent from their primary drug. Among these salutary lessons was a silver could not respond to these clues. But faced with this almost unremittingly negative feedback, a minority retrenched towards a commitment to continued drug Interchange; time to reflect use, especially the ones who from the start had been less convinced that their drug use Still to come are the implications of these Though trickery is not required, social really had been all bad. Over the next year, findings for training, research with legally skills and judgement are, because a ‘one size they struggled to control their drug use. coerced populations, and studies of linkage fits all’ programme risks negative interac- The same patients tended to be amongiv to aftercare. But in true motivational inter- tions. The truer therapists stay to motiva- the ones who at the end of the interview viewing style, now is a good time to summa- tional interviewing’s ‘It’s up to you’ stance, backpedalled in their commitment to rise and reflect. the less they will provoke clients unwilling change. At this stage therapists tried to get First, clearly there is something here to accept direction. The problem with main- their clients to tie up all the ends – no mat- which works most of the time and more taining this stance regardless, is that it may ter how loose – into a plan for tackling drug consistently and at less cost than the usual also short-change clients ready and willing use, one concrete enough to have explicit alternatives. What that ‘something’ is re- to follow the therapist’s lead or who feel criteria of success, and sufficiently well mains to be clearly defined. In every induc- unable to self-initiate change. grounded to withstand the anticipated pres- tion study in which motivational Other hazards await therapists who sures of life beyond treatment. interviewing has apparently had a positive forego sensitivity in favour of programmes Despite being tested in these ways, most overall impact, this can be explained by which mandate a review of the good things sustained the strength of their commitment ‘non-specific’ factors common to other about drug use, even if clients have moved and went on to express this in reduced drug therapies rather than the specific approach. beyond needing this as a way of establishing use. But a minority sharply backed down; ‘I Most common, and potentially most empathy, which land damningly negative wills’ or equivalent rapidly became ‘I’m not powerful, is the enthusiasm and faith of the assessments of drug use on people who may sure’. The strength of this final, concrete, therapists, often newly trained and/or asso- not be ready to see it that way, or seek com- public and verifiable commitment was the ciated with the approach’s developers mitment regardless of whether the ground single most reliable harbinger of whether studies 3, 4, 5, 8 & 12. Then there is extra has been firmed up sufficiently to support it. clients would later control their drug use.v assessment and/or feedback of assessment Done in this way, motivational interviewing Another significant juncture came about results (studies 3, 4, 5 & 8) and in some is not always the safe, ‘at least it can’t hurt’ two-thirds through each session when cases perhaps, simply spending time with a option it once seemed.6 therapists asked if the client was yet ready to sympathetic listener studies 3, 4, 8 & 11. Managers also need to exercise judge- change. Again, those who backtracked Finally, in two studies patients may have ment. Since these are what is researched, tended to do badly over the following year. perceived the interviews as an earlier start to manualised programmes gather an evidence It seemed that some clients reacted badly treatment studies 5 & 11. base around them and become seen as a to these attempts to push them forward. Ironically, studies in which some patients therapeutic gold standard, while principle- Instead of firming up their expressed com- did worse after a motivational interview show based approaches reliant on the right spirit mitment to curtailing drug use, they re- there is more to the approach than these and social and clinical skills remain unsup- versed, a setback followed by the predictable non-specific influences; if these were all ported. Staff and commissioners under outcomes in terms of actual drug use. As far there was to it, we would expect every pa- pressure54 to base practice on evidence may as could be determined, this was not just a tient to benefit. then transfer over-prescriptive research case of people who had a poor prognosis programmes in to practice, valuing adher- anyhow reacting poorly to counselling. SKILL AND SENSITIVITY NOT TRICKERY ence to protocol above interpersonal skills.3 The analysts cautioned that “a prescribed Rather than some psychological trickery,20 and less flexible approach to MI (as can motivational interviewing’s strength may be BACK TO BASICS occur with manual-guided interventions) that it provides a platform for these generic, No matter how well it is done, there is no could paradoxically yield worse outcomes relationship-building behaviours: empathy, universal answer to whether motivational among initially less motivated clients.” respect, optimism, enthusiasm, confidence. interviewing is an effective induction ap- Leading the client to review the good side of At a minimum, it seeks to avoid behaviours proach and preferable to the alternatives. their drug use is, they thought, particularly which erode these qualities; at best, discov- In the first instance, it depends on the risky; by fostering an ‘It wasn’t all bad’ ering motivational interviewing helps to nature of the blockages to turning up and perception it might pave the way for resist- generate them. One of the approach’s vir- staying in treatment. Where these are prima- ant reactions to assessment feedback. tues is that it instills optimism and demands rily being unconvinced that you have a What caused these reversals was, for sustained respect even in the face what problem that needs treating or that treat- motivational interviewing, an atypical de- would otherwise be demoralising clients.70 ment can help, motivational approaches

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should have a role. Where they are to do 12 Joe G.W. et al. “Retention and patient engagement models 41 Saunders B. et al. “The impact of a brief motivational inter- for different treatment modalities in DATOS.” Drug and Alcohol vention with opiate users attending a methadone programme.” with access-blocking administrative proce- Dependence: 1999, 57, p. 113—125. Addiction: 1995, 90, p. 415–424. dures, changing these is the first line of 13 Rubak S. et al. “Motivational interviewing: a systematic 42 Saunders B. et al. “Motivational intervention with heroin attack. Where they are to with the client’s review and meta-analysis.” British Journal of General Prac- users attending a methadone clinic” In: Miller W.R. et al. tice: 2005, 55, p. 305–312. Motivational interviewing: preparing people to change addic- over-stretched life and inadequate resources, 14 Miller W.R. et al. “Mesa Grande: a methodological analysis tive behaviour. Guilford Press, 1991, p. 279–292. no feasible amount of motivational en- of clinical trials of treatments for alcohol use disorders.” Addic- 43 Miller W.R. et al. “Motivational interviewing in drug abuse hancement will provide all the answers. tion: 2002, 97, p. 265–277. services: a randomized trial.” J. Consulting and Clinical Psy- 15 Burke B.L. et al. “The efficacy of motivational interviewing: chology: 2003, 71(4), p. 754–763. D When motivational interviewing does fit a meta-analysis of controlled clinical trials.” J. 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Studies in Alcohol: 46 Rohsenow D.J. et al. “Motivational enhancement and convinced they must change or determined 1996, 57, p. 229–243. coping skills training for cocaine abusers: effects on substance 18 Burke B.L. et al. “The efficacy of motivational interviewing and use outcomes.” Addiction: 2004, 99, p. 862–874. on a way to get there, but unsure whether its adaptation.” In: Miller W.R. et al, eds. Motivational interviewing: 47 Personal communication from Damaris Rohsenow, 2005. they want to. These are the conditions in preparing people for change. Guilford Press, 2002, p. 217-250. 48 Chambless D.L. et al. “Update on empirically validated which motivational interviewing has been 19 Dunn C. et al. “The use of brief interventions adapted from therapies, II.” The Clinical Psychologist: 1998, 51(1), p. 3–16. motivational interviewing across behavioral domains: a system- 49 Woody S.R. et al, eds. “Manuals for empirically supported most successful at improving retention and atic review.” Addiction: 2001, 96(12), p. 1725–1742. treatments: 1998 update.” The Clinical Psychologist: 1998, substance use outcomes. The effect is often 20 Hettema J. et al. “Motivational interviewing.” Annual Re- 51(1), p. 17–21. to even out response to treatment by pre- view of Clinical Psychology: 2005, 1, p. 91–111. 50 Miller W.R. et al. 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Health and Human Services, 1995. studies 3, 4, 9, 14 & 15. 22 Bien T. et al. “Motivational interviewing with alcohol outpa- 51 Kahler C.W. et al. “Motivational enhancement for 12-step But even in the most conducive of cir- tients.” Behav. & Cognitive Psychotherapy: 1993, 21, p. 347–356. involvement among patients undergoing alcohol detoxifica- 23 Dench S. et al. “The impact of brief motivational interven- tion.” Journal of Consulting and Clinical Psychology: 2004, cumstances, the approach requires sensitiv- tion at the start of an outpatient day programme for alcohol 72(4), p. 736–741. ity and social skills.55 That perhaps dependence.” Behavioural and Cognitive Psychotherapy: 52 Amrhein P.C. “How does motivational interviewing work? understates it. True-to-type motivational 2000, 28, p. 121–130. What client talk reveals.” J. Cognitive Psychotherapy: 2004, 18(4). 24 Donovan D.M. “Attrition prevention with individuals await- 53 Miller W.R. et al. Manual for the Motivational Interviewing interviewing is the application of sensitivity ing publicly funded drug treatment.” Addiction: 2001, 96, p. Skill Code (MISC). Version 2.0. University of New Mexico, 2003. and social skills. The bad news is that this is 1149-1160. 54 Reimer B. Strengthening evidence-based addictions pro- not a packageable ‘programme’ to be lifted 25 Wertz J. “Effect of motivational interviewing on treatment grams: a policy discussion paper. Alberta Alcohol and Drug participation, self-efficacy, and alcohol use at follow-up in Abuse Commission [etc], 2003. off the shelf – or is that the good news? inpatient alcohol dependent adults.” Dissertation Abstracts 55 Moyers T.B. et al. “What makes motivational interviewing International: 1994, 55(1), 219-B. work? 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Services etc, 1999. tional patients significantly hardened their intention to abstain from heroin or cut down. 28 Miller W.R. et al. “Enhancing motivation for change in 57 Miller W.R. “Motivational interviewing with problem drink- problem drinking: a controlled comparison of two therapist ers.” Behavioural Psychotherapy: 1983, 11, p. 147–172. iv The relationship was significant but not one-to-one: styles.” J. Consulting and Clin. Psychol.: 1993, 61, p. 455–461. patients who had not reacted badly to feedback may still 58 Klingemann H. et al. Promoting self change from problem have backpedalled. 29 Karno M.P. et al. “Less directiveness by therapists improves substance use. Practical implications for policy, prevention and drinking outcomes of reactant clients in alcoholism treatment.” J. treatment. Kluwer Academic Publishers, 2001. v Whether this would also be the case in normal practice Consulting and Clin. Psychol.: 2005, 73(2), p. 262–267. may depend on the context. 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